Domiciliary monitoring of exhaled nitric oxide in the management of asthma: a pilot study

BACKGROUND

Whether asthma patients could benefit from home monitoring for fractional exhaled nitric oxide (flow of 50 mL/s, FeNO50) is unknown. We explore the application value of home monitoring FeNO50 in daily asthma management.

METHODS

Twenty-two untreated, uncontrolled asthma patients were selected. Medical history, blood and sputum samples, pulmonary function, Asthma Control Test (ACT), and other clinical data of the subjects were collected. All subjects underwent daily monitoring for four weeks using a FeNO50 monitor and mobile spirometry (mSpirometry). The diurnal differences and dynamic changes were described. Compare the effect-acting time and the relative plateau of treatment between FeNO50 and mSpirometry monitoring.

RESULTS

In the first two weeks, the morning median (IQR) level of FeNO50 was 44 (35, 56) ppb, which was significantly higher than the evening median level [41 (32, 53) ppb, P = 0.028]. The median (IQR) effect-acting time assessed by FeNO50 was 4 (3, 5) days, which was significantly earlier than each measure of mSpirometry (P < 0.05). FeNO50 reached the relative plateau significantly earlier than FEV1 (15 ± 2 days vs. 21 ± 3 days, P < 0.001). After treatment, the daily and weekly variation rates of FeNO50 showed a gradually decreasing trend (P < 0.05). The ACT score, sputum eosinophils, and blood eosinophils also significantly improved (P ≤ 0.01).

CONCLUSIONS

The daily home monitoring of FeNO50 in asthmatic patients showed significant circadian rhythm, and the sensitivity of FeNO50 in evaluating the response to treatment was higher than mSpirometry. The daily and weekly variation rates of FeNO50 change dynamically with time, which may be used to assess the condition of asthma.

Satisfaction with home blood sampling methods and expectations for future point-of-care testing in phenylketonuria: Perspectives from patients and professionals

INTRODUCTION

Phenylketonuria (PKU) requires regular phenylalanine monitoring to ensure optimal outcome. However, home sampling methods used for monitoring suffer high pre-analytical variability, inter-laboratory variability and turn-around-times, highlighting the need for alternative methods of home sampling or monitoring.

METHODS

A survey was distributed through email and social media to (parents of) PKU patients and professionals working in inherited metabolic diseases in Denmark, The Netherlands, and United Kingdom regarding satisfaction with current home sampling methods and expectations for future point-of-care testing (POCT).

RESULTS

210 parents, 156 patients and 95 professionals completed the survey. Countries, and parents and patients were analysed together, in absence of significant group differences for most questions. Important results are: 1) Many patients take less home samples than advised. 2) The majority of (parents of) PKU patients are (somewhat) dissatisfied with their home sampling method, especially with turn-around-times (3-5 days). 3) 37% of professionals are dissatisfied with their home sampling method and 45% with the turn-around-times. 4) All responders are positive towards developments for POCT: 97% (n = 332) of (parents of) patients is willing to use a POC-device and 76% (n = 61) of professionals would recommend their patients to use a POC-device. 5) Concerns from all participants for future POC-devices are costs/reimbursements and accuracy, and to professionals specifically, accessibility to results, over-testing, patient anxiety, and patients adjusting their diet without consultation.

CONCLUSION

The PKU community is (somewhat) dissatisfied with current home sampling methods, highlighting the need for alternatives of Phe monitoring. POCT might be such an alternative and the community is eager for its arrival.

Evaluation of the accuracy of a UWB tracker for in-home positioning for older adults

The population of older adults is rapidly growing. In-home monitoring systems have been used to support aging-in-place. Ambient sensors or wearable localizers can be used but may be too low resolution, while camera systems are invasive to privacy. Ultra-wideband (UWB) localization offers precise positioning by placing anchors throughout the house and wearing a tag that is tracked by the anchors. In this study, the accuracy of UWB for indoor tracking was evaluated in a motion capture gait lab and in a mock condo in the Glenrose Rehabilitation Hospital. First, the configuration of UWB was tested, changing factors related to sampling time, anchor placement and line-of-sight. Comparing these factors to the configurations recommended by the manufacturer guidelines, accuracies remained within 14 cm. We then performed static and dynamic accuracy tests, with dynamic testing comprised of rolling and walking motions. In the motion capture lab, we found localization accuracies of 7.0 ± 11.1 cm while in the mock condo, we found accuracies of 27.3 ± 12.9 cm. Dynamic testing with rolling motions had an average of 19.1 ± 1.6 cm while walking was 20.5 ± 4.2 cm. The mean accuracy of UWB is within the 30 cm target for indoor localization.

Comparison of clinic and home blood pressure readings in higher risk pregnancies - Secondary analysis of the BUMP 1 trial

OBJECTIVE

To compare clinic and home blood pressure readings in higher risk pregnancies in the antenatal period from 20 weeks gestation, and to evaluate differences between the two modalities.

STUDY DESIGN

A cohort study comprising a secondary analysis of a large randomised controlled trial (BUMP 1).

POPULATION

Normotensive women at higher risk of pregnancy hypertension randomised to self-monitoring of blood pressure.

MAIN OUTCOME MEASURES

The primary outcome was the overall mean difference between clinic and home readings for systolic blood pressure (sBP) and diastolic blood pressure (dBP). Blood pressure readings were averaged across each gestational week for each participant and compared within the same gestational week. Calculations of the overall differences were based on the average difference for each week for each participant.

RESULTS

The cohort comprised 925 participants. In total, 92 (10 %) developed a hypertensive disorder during the pregnancy. A significant difference in the overall mean sBP (clinic - home) of 1.1 mmHg (0.5-1.6 95 %CI) was noted, whereas no significant difference for the overall mean dBP was found (0.0 mmHg (-0.4-0.4 95 %CI)). No tendency of proportional bias was noted based on Bland-Altman plots. Increasing body mass index in general increased the difference (clinic - home) for both sBP and dBP in a multivariate analysis.

CONCLUSIONS

No clinically significant difference was found between clinic and home blood pressure readings in normotensive higher risk pregnancies from gestational week 20+0 until 40+0. Clinic and home blood pressure readings might be considered equal during pregnancy in women who are normotensive at baseline.

Detection of paroxysmal atrial fibrillation preceding persistent atrial fibrillation in a horse using an implantable loop recorder with remote monitoring

Implantable loop recorders (ILRs) are increasingly used in equine cardiology to detect arrhythmias in the context of collapse, poor performance or monitoring for recurrence of atrial fibrillation (AF). However to date, the ILR has never been reported to be used with a remote monitoring functionality in horses, therefore the arrhythmia is only discovered when a clinician interrogates the ILR using dedicated equipment, which might delay diagnosis and intervention. This case report describes the use of an ILR with remote monitoring functionality in a horse with recurrent AF. The remote monitoring consisted of a transmission device located in the stable allowing daily transmission of arrhythmia recordings and functioning messages to an online server, available for the clinician to evaluate without specialised equipment. The ILR detected an episode of paroxysmal AF approximately 3 months after implantation. Seven months after implantation, initiation of persistent AF was seen on an episode misclassified by the ILR as bradycardia, and the horse was retired. This report shows the feasibility and benefits of remote monitoring for ILRs in horses, but also the shortcomings of current algorithms to interpret the equine electrocardiogram.

Detecting negative myoclonus during long-term home measurements using wearables

OBJECTIVE

The aim of this study was to develop a feasible method for the detection of negative myoclonus (NM) through long-term home measurements in patients with progressive myoclonus epilepsy type 1.

METHODS

The number and duration of silent periods (SP) associated with NM were detected during a 48 h home recording using wearable surface electromyography (EMG) sensors.

RESULTS

A newly developed algorithm was able to find short (50-69 ms), intermediate (70-100 ms), and long (101- 500 ms) SPs from EMG data. Negative myoclonus assessed by the algorithm correlated significantly with the video-recorded and physician-evaluated unified myoclonus rating scale (UMRS) scores of NM and action myoclonus. Silent period duration, number, and their combination, correlated strongly and significantly also with the Singer score, which assesses functional status and ambulation.

CONCLUSIONS

Negative myoclonus can be determined objectively using long-term EMG measurements in home environment. With long-term measurements, we can acquire more reliable quantified information about NM as a symptom, compared to short evaluation at the clinic.

SIGNIFICANCE

As measured using SPs, NM may be a clinically useful measure for monitoring disease progression or assessing antimyoclonic drug effects objectively.

[Electrical storm in patients with Automatic Implantable Defibrillator : A single Center study]

BACKGROUND

Electrical storms (ES) are serious cardiac emergencies associated with increased short-term mortality. The true incidence of ES in patients with an implantable cardioverter defibrillator (ICD) is still difficult to estimate because of the heterogeneous definition. The clinical presentation is variable and its management is multidisciplinary.

OBJECTIVE

The aim of the study was to analyze the epidemiological profile and evolution of a group of patients implanted with an ICD who had electrical storms detected by a home monitoring system.

METHODS

This is a single-center retrospective observational study, which included 14 patients who were implanted with ICDs, for primary or secondary prevention between 2008 and 2021. All of them were followed by home monitoring. All these patients had an ES detected by home monitoring and authenticated by ECG.

RESULTS

The mean age of the patients at the time of onset of the electrical storm was 75.4 ± 14.5 years, with extremes ranging from 49 to 101 years. Most of patients (n = 11) were male. The majority of them had underlying ischaemic cardiomyopathy (n = 12). In a third of cases (n = 5) patients were implanted for secondary prevention. The electrical storm was related to recurrent episodes of VT. No cases of VF were detected. Syncope was the most frequent clinical presentation (four patients). Nine patients received internal shocks, with an average of four shocks per patient. The triggering factor was myocardial ischaemia in four cases. Majority of patients were managed in the cardiac intensive care unit. Two patients were admitted to the intensive care unit. In addition to anti-arrhythmic treatment with amiodarone and beta blockers. Nine patients underwent ablation of ventricular tachycardia focus. Mortality was high (in half of the cases) mainly due to a cardiogenic shock.

CONCLUSION

This study shows that OR remain rare, but are still associated with high mortality. Home monitoring makes it possible to manage them earlier.

Patient and staff experiences of using technology-enabled and analogue models of remote home monitoring for COVID-19 in England: A mixed-method evaluation

OBJECTIVE

To evaluate patient and staff experiences of using technology-enabled ('tech-enabled') and analogue remote home monitoring models for COVID-19, implemented in England during the pandemic.

METHODS

Twenty-eight sites were selected for diversity in a range of criteria (e.g. pre-hospital or early discharge service, mode of patient data submission). Between February and May 2021, we conducted quantitative surveys with patients, carers and staff delivering the service, and interviewed patients, carers, and staff from 17 of the 28 services. Quantitative data were analysed using descriptive statistics and both univariate and multivariate analyses. Qualitative data were interpreted using thematic analysis.

RESULTS

Twenty-one sites adopted mixed models whereby patients could submit their symptoms using either tech-enabled (app, weblink, or automated phone calls) or analogue (phone calls with a health professional) options; seven sites offered analogue-only data submission (phone calls or face-to-face visits with a health professional). Sixty-two patients and carers were interviewed, and 1069 survey responses were received (18 % response rate). Fifty-eight staff were interviewed, and 292 survey responses were received (39 % response rate). Patients who used tech-enabled modes tended to be younger (p = 0.005), have a higher level of education (p = 0.011), and more likely to identify as White British (p = 0.043). Most patients found relaying symptoms easy, regardless of modality, though many received assistance from family or friends. Staff considered the adoption of mixed delivery models beneficial, enabling them to manage large patient numbers and contact patients for further assessment as needed; however, they suggested improvements to the functionality of systems to better fit clinical and operational needs. Human contact was important in all remote home monitoring options.

CONCLUSIONS

Organisations implementing tech-enabled remote home monitoring at scale should consider adopting mixed models which can accommodate patients with different needs; focus on the usability and interoperability of tech-enabled platforms; and encourage digital inclusivity for patients.

Domiciliary Fractional Exhaled Nitric Oxide and Spirometry in Monitoring Asthma Control and Exacerbations

BACKGROUND

Domiciliary measurements of airflow obstruction and inflammation may assist healthcare teams and patients in determining asthma control and facilitate self-management.

OBJECTIVE

To evaluate parameters derived from domiciliary spirometry and fractional exhaled nitric oxide (Feno) in monitoring asthma exacerbations and control.

METHODS

Patients with asthma were provided with hand-held spirometry and Feno devices in addition to their usual asthma care. Patients were instructed to perform twice-daily measurements for 1 month. Daily symptoms and medication change were reported through a mobile health system. The Asthma Control Questionnaire was completed at the end of the monitoring period.

RESULTS

One hundred patients had spirometry, of which 60 were given additional Feno devices. Compliance rates for twice-daily measurements were poor (median [interquartile range], 43% [25%-62%] for spirometry; 30% [3%-48%] for Feno); at least 15% of patients took little or no spirometry measurements and 40% rarely measured Feno. The coefficient of variation (CV) values in FEV1 and Feno were higher, and the mean % personal best FEV1 lower in those who had major exacerbations compared with those without (P < .05). Feno CV and FEV1 CV were associated with asthma exacerbation during the monitoring period (area under the receiver-operating characteristic curve, 0.79 and 0.74, respectively). Higher Feno CV also predicted poorer asthma control (area under the receiver-operating characteristic curve, 0.71) at the end of the monitoring period.

CONCLUSIONS

Compliance with domiciliary spirometry and Feno varied widely among patients even in the setting of a research study. However, despite significant missing data, Feno and FEV1 were associated with asthma exacerbations and control, making these measurements potentially clinically valuable if used.

Rapid Roll Out of a Pacemaker Home Monitoring Programme: A Patient Perspective

OBJECTIVE

To assess the safety, efficacy, and patient acceptability of a pacemaker home monitoring (HM) service.

METHODS

All patients receiving a new Biotronik (Biotronik, Berlin, Germany) pacemaker between March 2020 and February 2021 were contacted for participation. Participants were surveyed on their experience of pacemaker HM. HM alerts and remote wound monitoring rates were also assessed.

RESULTS

Of the patients contacted, 77% responded, with a mean age of 80.6±9.9 years. Of these, 95.8% agreed that the home monitoring (HM) has been beneficial. Two thirds preferred HM to face-to-face follow-up and two thirds felt safe with HM. Three themes were identified from the comments: reassurance, technology and data security. Forty-one percent (41%) of respondents would like more reassurance that their HM is working, 18% mentioned technology with mixed responses, and 4.7% cited cybersecurity or the use of their personal data as a concern. The average one-way patient journey saved was 24.3±16.7 km (15.1±10.4 miles). One in three HM alerts required action but only 3.4% were urgent. Remote wound review was successful in 59%.

CONCLUSIONS

The majority of patients prefer HM and almost all think it has been beneficial. It saves significant travel time and provides actionable alerts. The patient experience could be improved by reassuring patients that their device is being monitored.

The implantable cardiac monitor in heart failure patient: a possible new indication?

Implantable cardiac monitors (ICMs) have found increasing use in clinical practice over the years, proving, when used in high-risk populations, to facilitate the diagnosis of bradyarrhythmias and tachyarrhythmias requiring treatment. Experience with heart failure patients undergoing pacemaker (PMK) or implantable defibrillator (ICD) implantation, which allow for continuous electrocardiographic monitoring and transthoracic impedance assessment, has made it possible to identify predictors of heart failure flare-ups. In this context, the use of telemonitoring has been shown to ensure better management of patients with heart failure. These benefits cannot be assessed to date in patients with heart failure and left ventricular ejection fraction (LVEF) > 35% who have no indication for PMK or ICD implantation. This population has been shown to have a significant incidence of ventricular arrhythmias and bradyarrhythmias. In addition, a significant number of cerebrovascular events are observed in this population, largely attributable to the high incidence of atrial fibrillation (AF). In this population, the occurrence of AF has also been shown to have a negative impact on patients' prognosis; at the same time, a rhythm control strategy has been shown to be more beneficial in this area than a rate control strategy. Studies also suggest arrhythmias have a negative impact on the cognitive status and quality of life of heart failure patients. These reasons could justify the implantation of ICMs equipped with telemonitoring systems in heart failure patients. The information provided by the monitoring system, if properly managed, could bring benefits in terms of prognosis and quality of life along with a reduction in economic costs. We will try here, by answering a few questions, to assess whether there is an indication for ICM in heart failure, which patients should be candidates and how these patients should be managed.

Home Monitoring of Glaucoma Using a Home Tonometer and a Novel Virtual Reality Visual Field Device: Acceptability and Feasibility

OBJECTIVE

Our aim was to assess the acceptability and feasibility of iCare HOME tonometer (HT) and Virtual Field (VF) devices in the home monitoring of glaucoma.

DESIGN

Prospective feasibility and acceptability study.

SUBJECTS

Twenty patients (39 eyes) with primary open-angle glaucoma, open-angle glaucoma, ocular hypertension, or suspected glaucoma.

METHODS

Patients were trained and instructed to bring 2 devices home for 1 week and use the HT 4 times/day for 4 days and the VF 3 times total.

MAIN OUTCOME MEASURES

For acceptability, we conducted satisfaction surveys and semistructured, qualitative interviews with a thematic analysis. Feasibility was assessed by device usage and quality of tests.

RESULTS

Most patients (73.7%) felt that the HT was easy to use, and 100% of them found the HT useful. All patients (100%) felt that VF was easy to use, and 94.4% of them found the VF useful. All patients (100%) obtained acceptable intraocular pressure and completed a VF test at home. We identified 4 key themes, with 33 subthemes. The key themes include the following: (1) advantages of home monitoring; (2) difficulties with home monitoring; (3) future considerations in home monitoring; and (4) the experience of patients with glaucoma.

CONCLUSIONS

The HT and VF were acceptable and feasible in a small cohort of motivated subjects. Patients were able to perform these tests proficiently at home, and they were generally enthused to obtain more data about their intraocular health, as it allowed them a heightened sense of security and insight about their chronic disease, as well as a reduction in foreseeable barriers to care. Home monitoring may also improve upon glaucoma care by enhancing patient empowerment and fostering community bonds. The VF should be further evaluated to ensure validity.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Study protocol of an international patient-led registry in patients with pulmonary fibrosis using online home monitoring: I-FILE

BACKGROUND

Pulmonary fibrosis (PF) is caused by a heterogeneous group of diseases, with a high inter-individual variability in disease trajectory. Identifying disease progression in patients with PF has impact on clinical management decisions. However, strategies to early identify and predict disease progression for these patients are currently lacking. In this study, we aim to assess long-term FVC change in patients with PF measured with home spirometry, and evaluate the feasibility of a multinational patient-led registry in PF. In addition, we will assess validity of patient-reported outcomes (PROMs) for the different subgroups of patients with PF.

METHODS

In this international, prospective, multicenter, observational study, we aim to include 700 patients across seven European countries. Patients will monitor their disease course for a period of two years using an online home monitoring program (I-FILE), which includes home spirometry, pulse oximetry, and PROMs. Results will be directly sent to the hospital via the online application. Patients will be asked to perform daily home spirometry and pulse oximetry in the first three months, followed by once weekly measurements for a period of two years. PROMs will be completed in the online I-FILE application every six months, including the King's brief Interstitial Lung Disease Health Status, The EuroQol five dimensions five-level, Visual Analogue Scales on cough, dyspnea, fatigue and general complaints, Leicester Cough Questionnaire, Fatigue Assessment Scale, Work Productivity and Activity Impairment Questionnaire, Global Rating of Change Scale, and Living with Pulmonary Fibrosis questionnaire.

DISCUSSION

This study will provide much needed insights in disease trajectories of the different subgroups of patients with PF. Simultaneously, the I-FILE study will yield valuable information on the use and feasibility of home-based data collection. This international patient-led registry will facilitate trans-border collaboration to further optimize care and research for patients with PF.

TRIAL REGISTRATION

The study was registered on the 12th of March 2020 in the International Clinical Trial Registry, www.

CLINICALTRIALS

gov ; Identifier: NCT04304898.

Diagnostic yield of an insertable cardiac monitor in a large patient population

Background

Insertable cardiac monitors (ICMs) are increasingly used for cardiac rhythm diagnosis with expanding indications. Little has been reported about their use and efficacy.

Objective

The study sought to evaluate the clinical utility of a novel ICM (Biotronik BIOMONITOR III) including the time to diagnosis in unselected patients with different ICM indications.

Methods

Patients from 2 prospective clinical studies were included to determine the diagnostic yield of the ICM. The primary endpoint was time to clinical diagnosis per implant indication or to the first change in atrial fibrillation (AF) therapy.

Results

A total of 632 patients were included with a mean follow-up of 233 ± 168 days. Of 384 patients with (pre)syncope, 34.2% had a diagnosis at 1 year. The most frequent therapy was permanent pacemaker implantation. Of 133 patients with cryptogenic stroke, 16.6% had an AF diagnosis at 1 year, resulting in oral anticoagulation. Of 49 patients with an indication for AF monitoring, 41.0% had a relevant change in AF therapy based on ICM data at 1 year. Of 66 patients with other indications, 35.4% received a rhythm diagnosis at 1 year. Moreover, 6.5% of the cohort had additional diagnoses: 26 of 384 patients with syncope, 8 of 133 patients with cryptogenic stroke, and 7 of 49 patients with AF monitoring.

Conclusion

In a large unselected patient population with heterogeneous ICM indications, the primary endpoint of rhythm diagnosis was achieved in ∼1 in 4, and additional clinically relevant findings was achieved in 6.5% of patients at short-term follow-up.

Benefits and barriers of home blood pressure monitoring in pregnancy: perspectives of obstetric doctors from a Ghanaian tertiary hospital

BACKGROUND

Delayed diagnosis of preeclampsia contributes to maternal morbidity and mortality. Patient-performed home blood pressure monitoring facilitates more frequent monitoring and earlier diagnosis. However, challenges may exist to implementation in low- and middle income-countries.

METHODS

This cross-sectional mixed methods study evaluated obstetric doctors' perspectives on the benefits of and barriers to the implementation of home blood pressure monitoring among pregnant women in Ghana. Participants were doctors providing obstetric care at Korle Bu Teaching Hospital. Electronic surveys were completed by 75 participants (response rate 49.3%), consisting of demographics and questions on attitudes and perceived benefits and challenges of home BP monitoring. Semi-structured interviews were completed by 22 participants to expand on their perspectives.

RESULTS

Quantitative and qualitative results converged to highlight that the current state of blood pressure monitoring among pregnant women in Ghana is inadequate. The majority agreed that delayed diagnosis of preeclampsia leads to poor health outcomes in their patients (90.6%, n = 68) and earlier detection would improve outcomes (98.7%, n = 74). Key qualitative benefits to the adoption of home blood pressure monitoring were patient empowerment and trust of diagnosis, more quantity and quality of blood pressure data, and improvement in systems-level efficiency. The most significant barriers were the cost of monitors, lack of a communication system to convey abnormal values, and low health literacy. Overall, doctors felt that most barriers could be overcome with patient education and counseling, and that benefits far outweighed barriers. The majority of doctors (81.3%, n = 61), would use home BP data to inform their clinical decisions and 89% (n = 67) would take immediate action based on elevated home BP values. 91% (n = 68) would recommend home BP monitoring to their pregnant patients.

CONCLUSION

Obstetric doctors in Ghana strongly support the implementation of home blood pressure monitoring, would use values to inform their clinical management, and believe it would improve patient outcomes. Addressing the most significant barriers, including cost of blood pressure monitors, lack of a communication system to convey abnormal values, and need for patient education, is essential for successful implementation.

Telemonitoring in heart failure patients: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Home telemonitoring has been used as a modality to prevent readmission and improve outcomes for patients with heart failure. However, studies have produced conflicting outcomes over the years.

AIM

To determine the aggregate effect of telemonitoring on all-cause mortality, heart failure-related mortality, all-cause hospitalization, and heart failure-related hospitalization in heart failure patients.

METHODS

We conducted a systematic review and meta-analysis of 38 home telemonitoring randomized controlled trials involving 14993 patients. We also conducted a sensitivity analysis to examine the effect of telemonitoring duration, recent heart failure hospitalization, and age on telemonitoring outcomes.

RESULTS

Our study demonstrated that home telemonitoring in heart failure patients was associated with reduced all-cause [relative risk (RR) = 0.83, 95% confidence interval (CI): 0.75-0.92, P = 0.001] and cardiovascular mortality (RR = 0.66, 95%CI: 0.54-0.81, P < 0.001). Additionally, telemonitoring decreased the all-cause hospitalization (RR = 0.87, 95%CI: 0.80-0.94, P = 0.002) but did not decrease heart failure-related hospitalization (RR = 0.88, 95%CI: 0.77-1.01, P = 0.066). However, prolonged home telemonitoring (12 mo or more) was associated with both decreased all-cause and heart failure hospitalization, unlike shorter duration (6 mo or less) telemonitoring.

CONCLUSION

Home telemonitoring using digital/broadband/satellite/wireless or blue-tooth transmission of physiological data reduces all-cause and cardiovascular mortality in heart failure patients. In addition, prolonged telemonitoring (≥ 12 mo) reduces all-cause and heart failure-related hospitalization. The implication for practice is that hospitals considering telemonitoring to reduce heart failure readmission rates may need to plan for prolonged telemonitoring to see the effect they are looking for.

Analysis of the Long-term Visual Outcomes of ForeseeHome Remote Telemonitoring: The ALOFT Study

PURPOSE

To evaluate long-term visual acuity (VA) and performance of a monitoring strategy with a self-operated artificial-intelligence-enabled home monitoring system in conjunction with standard care for early detection of neovascular age-related macular degeneration (nAMD).

DESIGN

Retrospective review.

SUBJECTS

Patients with dry-age-related macular degeneration from 5 referral clinics.

METHODS

Clinical data of patients monitored with ForeseeHome (FSH) device from August 2010 to July 2020 were reviewed.

MAIN OUTCOME MEASURES

Visual acuity at baseline, VA at diagnosis of nAMD for eyes that converted while monitored, and VA from the final study follow-up, weekly frequency of use, duration of monitoring, modality of conversion diagnosis (system alert vs. detection by other standard care means), and duration and number of treatments since conversion to final study follow-up were collected.

RESULTS

We reviewed 3334 eyes of 2123 patients with a mean (standard deviation [SD]) age of 74(8) years, monitored for a mean (SD) duration of 3.1 (2.4) years, with a total of 1 706 433 tests in 10 474 eye-monitoring years. The mean (SD) weekly use per patient was 5.2 (3.4), and it was persistent over the usage period. Two hundred eighty-five eyes converted while monitored at an annual rate of 2.72% and were treated with a mean (SD) 17.3 (16.5) injections over a mean (SD) 2.7 (2.0) years, with 6.4 (3.1) injections per year for eyes treated for > 1 year. The median VAs at baseline and at final follow-up for eyes that did not convert were 20/27 and 20/34 with a median change of 0.0 letters. The median VAs at baseline, conversion, and final follow-up for eyes that converted during the monitoring period were 20/30, 20/39, and 20/32 with a median change from baseline to conversion, baseline to recent, and conversion to recent of -4, -4, and 0 letters, respectively. Fifty-two percent of conversions detected had a system alert before conversion. Forty-eight percent of patients were detected by symptoms or routine visit. Patients experienced a non-nAMD alert on average every 4.6 years. At conversion and at final follow-up, the proportion (95% CI) of eyes that maintained ≥ 20/40 was 84% (78% to 88%) and 82% (76% to 86%), respectively.

CONCLUSIONS

Patients in the FSH monitoring program showed excellent long-term VA years after conversion to nAMD.

Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia

BACKGROUND

Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic.

METHODS

A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews.

RESULTS

All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data.

CONCLUSION

Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

Evaluation of a self-imaging SD-OCT system designed for remote home monitoring

PURPOSE

To compare identification rates of retinal fluid of the Notal Vision Home Optical Coherence Tomography (OCT) device (NVHO) when used by people with age-related macular degeneration (AMD) to those captured by a commercial OCT.

METHODS

Prospective, cross-sectional study where patients underwent commercial OCT imaging followed by self-imaging with either the NVHO 2.5 or the NVHO 3 in clinic setting. Outcomes included patients' ability to acquire analyzable OCT images with the NVHO and to compare those with commercial images.

RESULTS

Successful images were acquired with the NVHO 2.5 in 469/531 eyes (88%) in 264/290 subjects (91%) with the mean (SD) age of 78.8 (8.8); 153 (58%) were female with median visual acuity (VA) of 20/40. In the NVHO 3 cohort, 69 eyes of 45 subjects (93%) completed the self-imaging. Higher rates of successful imaging were found in eyes with VA ≥ 20/320. Positive percent agreement/negative percent agreement for detecting the presence of subretinal and/or intraretinal fluid when reviewing for fluid in three repeated volume scans were 97%/95%, respectively for the NVHO v3.

CONCLUSION

Self-testing with the NVHO can produce high quality images suitable for fluid identification by human graders, suggesting the device may be able to complement standard-of-care clinical assessments and treatments.

Telemedicine and cystic fibrosis: Do we still need face-to-face clinics?

There has been growing interest in telemedicine for cystic fibrosis over recent years based largely on convenience for patients and/or increasing the frequency of surveillance and early detection which, it is assumed, could improve treatment outcomes. During 2020, the covid-19 pandemic catalysed the pace of development of this field, as CF patients were presumed to be at high risk of infection. Most clinics adapted to digital platforms with provision of lung function monitoring and sample collection systems. Here, we present the views of multidisciplinary team members at a large paediatric CF centre on what has worked well and what requires further optimisation in the future. In response to the question posed, 'Do we still need face to face clinics?' our answer is 'Yes, but not every time, and not for everyone'.

Investigation of respiratory rate in patients with cystic fibrosis using a minimal-impact biomotion system

Background

In this study we tested the hypothesis that in patients with cystic fibrosis (pwCF) respiratory rate (RR) is associated with antibiotic treatment, exacerbation status, forced expiratory volume in one second (FEV1) and C-reactive protein (CRP).

Methods

Between June 2018 and May 2019, we consecutively enrolled pwCF who were referred to our hospital. We determined RR and heart rate (HR) by using the minimal-impact system VitaLog during the hospital stay. Furthermore, we performed spirometry and evaluated CRP.

Results

We included 47 patients: 20 with pulmonary exacerbation and 27 without. RR decreased in patients with exacerbation (27.5/min (6.0/min) vs. 24.4/min (6.0/min), p = 0.004) and in patients with non-exacerbation (22.5/min (5.0/min) vs. 20.9/min (3.5/min), p = 0.024). Patients with exacerbation showed higher RR than patients with non-exacerbation both at the beginning (p = 0.004) and at the end of their hospital stay (p = 0.023). During the hospital stay, HR did not change in the total cohort (66.8/min (11.0/min) vs. 66.6/min (12.0/min), p = 0.440). Furthermore, we did not find significant differences between patients with exacerbation and patients with non-exacerbation (67.0/min (12.5/min) vs. 66.5/min (10.8/min), p = 0.658). We observed a correlation of ρ = -0.36 between RR and FEV1. Moreover, we found a correlation of ρ = 0.52 between RR and CRP.

Conclusion

In pwCF requiring intravenous therapy, respiratory rate is higher at their hospital admittance and decreased by the time of discharge; it is also associated with C-reactive protein. Monitoring RR could provide important information about the overall clinical conditions of pwCF.

[Positive Project: maintenance and improvement of intrinsic capacity involving primary care and caregivers through a home monitoring system and a telematic services platform.]

POSITIVE (acronym for Maintaining and imPrOving the intrinSIc capaciTy Involving primary care and caregiVErs) is an EIT Health funded project. Its main objective is to make available to the elderly population, caregivers and the different clinical professionals involved in their care, both primary and hospital care, a home monitoring system that allows a better management and treatment of frailty, in order to maintain or improve the intrinsic capacity of the elderly, as well as to avoid disability through a telematic platform of services. The POSITIVE technological ecosystem allows data collection and remote monitoring of the state of pre-fragility and fragility in a community environment, enabling early interventions aimed at preventing disability and dependence. The home monitoring system consists of a series of questionnaires on the state of health, and 3 sensors that measure variables with high predictive power of adverse events: gait speed, power in the lower extremities and involuntary weight loss. With this system, older people are under constant supervision. In addition, POSITIVE has an automatic system of personalized prescription of physical exercise based on the VIVIFRAIL program, as well as a nutritional plan and monitoring of functional status. Using the platform's services, caregivers can be aware of any impairment. For their part, primary care professionals receive alarms related to potentially dangerous decreases in intrinsic capacity, giving them the possibility to adjust treatments accordingly with the help of a decision support system while the geriatrics service can be involved if deemed necessary.

The feasibility of home monitoring of young people with cystic fibrosis: Results from CLIMB-CF

BACKGROUND

CF is traditionally assessed in clinic. It is unclear if home monitoring of young people with CF is feasible or acceptable. The COVID-19 pandemic has made home monitoring more of a necessity. We report the results of CLIMB-CF, exploring home monitoring's feasibility and potential obstacles.

METHODS

We designed a mobile app and enrolled participants with CF aged 2-17 years and their parents for six months. They were asked to complete a variety of measures either daily or twice a week. During the study, participants and their parents completed questionnaires exploring depression, anxiety and quality of life. At the end of the study parents and participants completed acceptability questionnaires.

RESULTS

148 participants were recruited, 4 withdrew prior to starting the study. 82 participants were female with median (IQR) age 7.9 (5.2-12 years). Median data completeness was 40.1% (13.6-69.9%) for the whole cohort; when assessed by age participants aged ≥ 12 years contributed significantly less (15.6% [9.8-30%]). Data completeness decreased over time. There was no significant difference between parental depression and anxiety scores at the start and the end of the study nor in CFQ-R respiratory domain scores for participants ≥ 14 years. The majority of participants did not feel the introduction of home monitoring impacted their daily lives.

CONCLUSIONS

Most participants felt home monitoring did not negatively impact their lives and it did not increase depression, anxiety or decrease quality of life. However, uptake was variable, and not well sustained. The teenage years pose a particular challenge and further work is required.

Potential of remote monitoring to prevent sensing and detection failures in implantable cardioverter defibrillators

BACKGROUND

Sensing malfunction and misinterpretation of intracardiac electrograms (IEGMs) in patients with implantable cardioverter defibrillators (ICDs) may lead to inadequate device activity such as inappropriate shock delivery or unnecessary mode-switching. Remote monitoring has the potential for early detection of sensing malfunction or misclassification and may thus prevent adverse device activity. Therefore, the authors analyzed the amount, nature, and distribution of misclassification in current ICD and cardiac resynchronization therapy defibrillator technology using the device transmissions of the IN-TIME study population.

METHODS

All transmitted tachyarrhythmic episodes in the 664 IN-TIME patients, comprising 2214 device-classified atrial fibrillation (DC-AF) episodes lasting ≥ 30 s and 1330 device-classified ventricular tachycardia or fibrillation (DC-VT/VF) episodes, were manually analyzed by two experienced cardiologists.

RESULTS

After evaluation of all DC-VT/VF episodes, a total of 300 VT/VF events (23.1%) were false-positive, with supraventricular tachycardia being the most frequent cause (51.7%), followed by atrial fibrillation (21.3%) and T‑wave oversensing (21.0%). A total of 15 patients with false-positive DC-VT/VF received inappropriate shocks. According to the inclusion criteria, 616 IEGMs with DC-AF were assessed. A total of 19.7% were false-positive AF episodes and R‑wave oversensing was the most common reason (55.9%).

CONCLUSIONS

Remote monitoring offers the opportunity of early detection of signal misclassification and thus early prevention of adverse device reaction, such as inappropriate shock delivery or mode-switching with intermittent loss of atrioventricular synchrony, by correcting the underlying causes.

Toward Smart Monitoring with Phones, Watches, and Wearable Sensors

Smartphones are increasingly powerful computers that fit in our pocket. Thanks to dedicated applications or "Apps," they can connect with external sensors to record, analyze, display, store, and share multiple physiologic signals and data. In addition, because modern smartphones are equipped with accelerometers, gyroscopes, cameras, and pressure sensors, they can also be used to directly gather physiologic information. Smartphones and connected sensors are creating opportunities to empower patients, individualize perioperative care, follow patients during their surgical journey, and simplify clinicians' life.

[Telemedical applications in ophthalmology in times of COVID-19]

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic access to and utilization of ophthalmologic healthcare providers was partially restricted.

OBJECTIVE

This article provides an overview of already available tele-ophthalmologic applications for better care during the pandemic as well as those still under development.

MATERIAL AND METHODS

The study included an analysis of current scientific publications, analysis of unrestricted screening applications in smart device app stores as well as telemetric medical products specifically designed for home monitoring and discussion of the requirements of an integrated ophthalmologic video consultation.

RESULTS

There is significant interest in tele-ophthalmologic applications and devices as evidenced by a rise in the number of relevant publications. Freely available screening tests for smart phones and tablets are as a rule currently not validated and show significant discrepancies from established standard tests. Telemetric medical devices show great potential for home monitoring in chronic ophthalmologic diseases but must first become established in the clinical routine.

CONCLUSION

There is an unmet need for systematic analysis, development and validation of telemedical applications and medical products for ophthalmology in order to advantageously utilize the potential of telemedicine and to incorporate this into an ophthalmologic video consultation.

Normative data on spontaneous stride velocity, stride length, and walking activity in a non-controlled environment

Background

Normative data are necessary for validation of new outcome measures. Recently, the 95th centile of stride speed was qualified by the European Medicines Agency as a valid secondary outcome for clinical trials in subjects with Duchenne muscular dystrophy. This study aims to obtain normative data on spontaneous stride velocity and length in a non-controlled environment and their evolution after 12 months.

Method

Ninety-one healthy volunteers (50 females, 41 males), with a mean age of 16 years and 2 months, were recruited and assessed at baseline and 12 months later. The 4-stair climb, 6-min walk test, 10-m walk test and rise from floor assessments were performed. Stride length, stride velocity, and the distance walked per hour were studied in an everyday setting for one month after each evaluation.

Results

Of the 91 subjects assessed, 82 provided more than 50 h of recordings at baseline; and 73 subjects provided the same at the end of the year. We observed significant positive correlations of the stride length with age and height of participants, and a significant increase of the median stride length in children after the period. In this group, the 95th centile stride velocity was not correlated with age and was stable after one year. All measures but the 10MWT were stable in adults after a one-year period.

Conclusion

This study provides with data on the influence of age, height, and gender on stride velocity and length as well as accounting for natural changes after one year in controls.

Home Spirometry Telemonitoring for Early Detection of Bronchiolitis Obliterans Syndrome in Patients with Chronic Graft-versus-Host Disease

Early detection of bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplantation (HCT) depends on recognition of subclinical spirometric changes, which is possible only with frequent interval spirometry. We evaluated the feasibility of home monitoring of weekly spirometry via a wireless handheld device and a web monitoring portal in a cohort of high-risk patients for the detection of lung function changes preceding BOS diagnosis. In this observational study, 46 patients with chronic graft-versus-host disease or a decline in forced expiratory volume in 1 second (FEV₁) of unclear etiology after allogeneic HCT were enrolled to perform weekly home spirometry with a wireless portable spirometer for a period of 1 year. Measurements were transmitted wirelessly to a Cloud-based monitoring portal. Feasibility evaluation included adherence with study procedures and an assessment of the home spirometry measurements compared with laboratory pulmonary function tests. Thirty-six patients (78%) completed 1 year of weekly monitoring. Overall adherence with weekly home spirometry measurements was 72% (interquartile range, 47% to 90%), which did not meet the predetermined threshold of 75% for high adherence. Correlation of home FEV₁ with laboratory FEV₁ was high, with a bias of 0.123 L (lower limit, -0.294 L; upper limit, 0.541 L), which is within acceptable limits for reliability. Of the 12 patients who were diagnosed with BOS or suspected BOS during the study period, 9 had an antecedent FEV₁ decline detected by home spirometry. Our data indicate that wireless handheld spirometry performed at home in a high-risk HCT cohort is feasible for close monitoring of pulmonary function and appears to facilitate early detection of BOS.

Self-examination low-cost full-field OCT (SELFF-OCT) for patients with various macular diseases

PURPOSE

The treatment guidelines for many macular diseases rely on frequent monitoring with optical coherence tomography (OCT). However, the burden of frequent disease control leads to low therapy adherence in real life. OCT home monitoring would address this issue but requires an inexpensive and self-operable device. With self-examination low-cost full-field OCT (SELFF-OCT), our group has introduced a novel technology that may fulfill both requirements. In this pilot study, we report the initial experiences with a clinical prototype.

METHODS

Fifty-one patients with different macular diseases were recruited in a cross-sectional study. The most common diseases were age-related macular degeneration (AMD; 39/51), diabetic macular edema (DME; 6/51), and retinal vein occlusion (RVO; 3/51). Patients received a short training in device usage and then performed multiple self-scans with the SELFF-OCT device. For comparison, scans with a standard clinical spectral domain (SD-)OCT were taken.

RESULTS

After a brief training, 77% of the patients were able to successfully acquire images that were clinically gradable. No significant influence on success could be found for age (p = 0.08) or BCVA (p = 0.97). Relevant disease biomarkers in the most common retinal diseases could be detected.

CONCLUSIONS

SELFF-OCT was used successfully for retinal self-examination and in the future could be used for retinal home monitoring. Future improvements in technology are expected to improve success rates and image quality.

TRIAL REGISTRATION

The Trial was registered in the German Trial Register under the number DRKS00013755 on 14.03.2018.

Home vision monitoring in patients with maculopathy: Real-life study of the OdySight application

INTRODUCTION

The goal of the present study was to analyze the implementation and clinical efficacy of OdySight, a mobile medical application for the remote monitoring of patients with maculopathy.

MATERIALS AND METHODS

In all, 60 patients with edematous maculopathies receiving traditional clinical treatment (PRN or Treat & Extend) were provided with OdySight to detect changes in visual acuity from home. To determine both the feasibility and reliability of the application, its use by patients (both testing and game play), as well as the processing of alerts by the clinical team, were analyzed during the first year.

RESULTS

The female-to-male ratio was 3:2, with a mean age of 64 years. 52% of patients presented with age-related macular degeneration, 31% with high myopia, 11% with retinal vein occlusion, and 6% with diabetic maculopathy. The conversion rate (defined as the percentage of patients completing at least one test following prescription) and the nine-month retention rate (percentage of active patients) were 61% and 24% respectively. Patients aged 50 to 70 years and those whose use of the app included game play represent 75% of active patients at 9 months. The 22 active patients performed 483 visual acuity tests, completed 1,667 game sessions, and underwent 77 in-person consultations. During the trial period, the clinical team processed 19 alerts, on average in fewer than 6 days. Decreases in visual acuity were detected with a sensitivity of 92% and specificity of 99%.

DISCUSSION

The use of connected and mobile devices today is widespread, as is interest in mobile medical applications. Long-term treatments for maculopathies can be a difficult burden to bear, both for patients and healthcare practitioners. Overcoming the challenges associated with the successful remote detection of recurrences thus represents a significant opportunity for improving patient care. The implementation of novel digital tools requires the cooperation of the clinical team as a whole, to both inform and motivate patients. OdySight demonstrates satisfactory detection rates, thanks to reliable and reproducible home testing, and can thus serve as a supplementary tool for patients whose consultations are often spaced several months apart. Implementation can be nonetheless improved by facilitating alert processing, a goal which necessitates active adaptation of clinical practices. In general, active patients were very satisfied with this personalized service.

CONCLUSION

Improved medical support, plus the amusing nature of the tests and games, both bolster long-term use of the OdySight app. The application allows for the remote monitoring of changes in visual acuity and affords patients and practitioners an added level of protection, particularly during long intervals between treatments and at the end of a treatment course. To ensure proper implementation, clinics should focus on reinforcing and modernizing the clinical pathway, from patient intake to the injection room.

Perspectives and recommendations of individuals with tetraplegia regarding wearable cameras for monitoring hand function at home: Insights from a community-based study

CONTEXT

Wearable cameras have great potential for producing novel outcome measures of upper limb (UL) function and guiding care in individuals with cervical spinal cord injury (cSCI) living in the community. However, little is known about the perspectives of individuals with cSCI on the potential adoption of this technology.

OBJECTIVE

To analyze feedback from individuals with cSCI regarding the use of wearable cameras to record daily activities at home, in order to define guidelines for improving the design of this technology and fostering its implementation to optimize UL rehabilitation.

DESIGN

Mixed-methods study.

PARTICIPANTS

Thirteen adults with cSCI C3-C8 AIS A-D impairment.

MEASURES

Interview including survey and semi-structured questions.

RESULTS

Participants felt that this technology can provide naturalistic information regarding hand use to clinicians and researchers, which in turn can lead to better assessments of UL function and optimized therapies. Participants described the technology as easy-to-use but often reported discomfort that prevented them from conducting long recordings of fully natural activities. Privacy concerns included the possibility to capture household members and personal information displayed on objects (e.g. smartphones).

CONCLUSION

We provide the first set of guidelines to help researchers and therapists understand which steps need to be taken to translate wearable cameras into outpatient care and community-based research for UL rehabilitation. These guidelines include miniaturized and easy-to-wear cameras, as well as multiple measures for preventing privacy concerns such as avoiding public spaces and providing control over the recordings (e.g. start and stop the recordings at any time, keep or delete a recording).

Ensemble deep model for continuous estimation of Unified Parkinson's Disease Rating Scale III

BACKGROUND

Unified Parkinson Disease Rating Scale-part III (UPDRS III) is part of the standard clinical examination performed to track the severity of Parkinson's disease (PD) motor complications. Wearable technologies could be used to reduce the need for on-site clinical examinations of people with Parkinson's disease (PwP) and provide a reliable and continuous estimation of the severity of PD at home. The reported estimation can be used to successfully adjust the dose and interval of PD medications.

METHODS

We developed a novel algorithm for unobtrusive and continuous UPDRS-III estimation at home using two wearable inertial sensors mounted on the wrist and ankle. We used the ensemble of three deep-learning models to detect UPDRS-III-related patterns from a combination of hand-crafted features, raw temporal signals, and their time-frequency representation. Specifically, we used a dual-channel, Long Short-Term Memory (LSTM) for hand-crafted features, 1D Convolutional Neural Network (CNN)-LSTM for raw signals, and 2D CNN-LSTM for time-frequency data. We utilized transfer learning from activity recognition data and proposed a two-stage training for the CNN-LSTM networks to cope with the limited amount of data.

RESULTS

The algorithm was evaluated on gyroscope data from 24 PwP as they performed different daily living activities. The estimated UPDRS-III scores had a correlation of [Formula: see text] and a mean absolute error of 5.95 with the clinical examination scores without requiring the patients to perform any specific tasks.

CONCLUSION

Our analysis demonstrates the potential of our algorithm for estimating PD severity scores unobtrusively at home. Such an algorithm could provide the required motor-complication measurements without unnecessary clinical visits and help the treating physician provide effective management of the disease.

Measuring freezing of gait during daily-life: an open-source, wearable sensors approach

Background

Although a growing number of studies focus on the measurement and detection of freezing of gait (FoG) in laboratory settings, only a few studies have attempted to measure FoG during daily life with body-worn sensors. Here, we presented a novel algorithm to detect FoG in a group of people with Parkinson’s disease (PD) in the laboratory (Study I) and extended the algorithm in a second cohort of people with PD at home during daily life (Study II).

Methods

In Study I, we described of our novel FoG detection algorithm based on five inertial sensors attached to the feet, shins and lumbar region while walking in 40 participants with PD. We compared the performance of the algorithm with two expert clinical raters who scored the number of FoG episodes from video recordings of walking and turning based on duration of the episodes: very short (< 1 s), short (2–5 s), and long (> 5 s). In Study II, a different cohort of 48 people with PD (with and without FoG) wore 3 wearable sensors on their feet and lumbar region for 7 days. Our primary outcome measures for freezing were the % time spent freezing and its variability.

Results

We showed moderate to good agreement in the number of FoG episodes detected in the laboratory (Study I) between clinical raters and the algorithm (if wearable sensors were placed on the feet) for short and long FoG episodes, but not for very short FoG episodes. When extending this methodology to unsupervised home monitoring (Study II), we found that percent time spent freezing and the variability of time spent freezing differentiated between people with and without FoG (p < 0.05), and that short FoG episodes account for 69% of the total FoG episodes.

Conclusion

Our findings showed that objective measures of freezing in PD using inertial sensors on the feet in the laboratory are matching well with clinical scores. Although results found during daily life are promising, they need to be validated. Objective measures of FoG with wearable technology during community-living would be useful for managing this distressing feature of mobility disability in PD.

Design of a randomized controlled trial to evaluate effectiveness of methotrexate versus prednisone as first-line treatment for pulmonary sarcoidosis: the PREDMETH study

BACKGROUND

Treatment of pulmonary sarcoidosis is recommended in case of significant symptoms, impaired or deteriorating lung function. Evidence-based treatment recommendations are limited and largely based on expert opinion. Prednisone is currently the first-choice therapy and leads to short-term improvement of lung function. Unfortunately, prednisone often has side-effects and may be associated with impaired quality of life. Methotrexate is presently considered second-line therapy, and appears to have fewer side-effects.

OBJECTIVE

The primary objective of this trial is to investigate the effectiveness and tolerability of methotrexate as first-line therapy in patients with pulmonary sarcoidosis compared with prednisone. The primary endpoint of this study will be the change in hospital-measured Forced Vital Capacity (FVC) between baseline and 24 weeks. Secondary objectives are to gain more insights in response to therapy in individual patients by home spirometry and patient-reported outcomes. Blood biomarkers will be examined to find predictors of response to therapy, disease progression and chronicity, and to improve our understanding of the underlying disease mechanism.

METHODS/DESIGN

In this prospective, randomized, non-blinded, multi-center, non-inferiority trial, we plan to randomize 138 treatment-naïve patients with pulmonary sarcoidosis who are about to start treatment. Patients will be randomized in a 1:1 ratio to receive either prednisone or methotrexate in a predefined schedule for 24 weeks, after which they will be followed up in regular care for up to 2 years. Regular hospital visits will include pulmonary function assessment, completion of patient-reported outcomes, and blood withdrawal. Additionally, patients will be asked to perform weekly home spirometry, and record symptoms and side-effects via a home monitoring application for 24 weeks.

DISCUSSION

This study will be the first randomized controlled trial comparing first-line treatment of prednisone and methotrexate and provide valuable data on efficacy, safety, quality of life and biomarkers. If this study confirms the hypothesis that methotrexate is as effective as prednisone as first-line treatment for sarcoidosis but with fewer side-effects, this will lead to improvement in care and initiate a change in practice. Furthermore, insights into the immunological mechanisms underlying sarcoidosis pathology might reveal new therapeutic targets.

TRIAL REGISTRATION

The study was registered on the 19th of March 2020 in the International Clinical Trial Registry, www.clinicaltrials.gov; ID NCT04314193 .

Prospective surveillance model in the home for breast cancer-related lymphoedema: a feasibility study

PURPOSE

The aim of this study was to assess the feasibility of delivering a prospective surveillance model in the home over 6 months for women at high risk of developing lymphoedema.

METHODS

A single-group, intervention study recruited 20 women who had surgical and medical treatment for confirmed node-positive invasive breast cancer and therefore at high risk of developing arm lymphoedema. Participants received a package including Bioimpedance Spectroscopy (BIS) monitoring, lymphoedema education and support to promote self-management and physical activity.

RESULTS

Participants adhered to BIS monitoring 74% of the time, and felt extremely confident in using the device. By 6 months, mean BIS L-Dex scores had increased from 3.5 (SD 5.6) to 8.4 (SD 11.1); five women (25%) who experienced >  + 6.5 increase in L-Dex score were fitted with a compression garment. Self-reported symptoms and distress decreased by 0.4 out of 10 (95% CI 0.1 to 0.7); number of self-management strategies used increased by 0.6 (95% CI 0.1 to 1.2); and planned exercise increased by 2.8 h/week (95% CI 0.4 to 5.2).

CONCLUSIONS

These findings indicate a prospective surveillance model of care in the home with BIS is feasible and associated with increased self-management. A Phase II randomised trial is warranted as well as research exploring the costs associated with implementing this model of care for high-risk individuals.

Progress in heart failure management in the Netherlands and beyond: long-term commitment to deliver high-quality research and patient care

Heart failure (HF) remains a major global problem. In the Netherlands, 1.5–2.0% of the total population is diagnosed with HF. Over 30,000 HF patients are admitted annually in the Netherlands, and this number is expected to further increase given the ageing population and the chronic nature of HF. Despite ongoing efforts to reduce the burden of HF, morbidity and mortality rates of this disease remain high. However, several new treatment modalities have become available or are expected to become available in the coming years. This review will provide an overview of HF research conducted in the Netherlands (often in an international setting) that may have clinical consequences for diagnosis, treatment and prevention of HF, and will also evaluate outcomes of larger clinical trials that have been conducted in the Netherlands.

SENS-U: continuous home monitoring of natural nocturnal bladder filling in children with nocturnal enuresis - a feasibility study

INTRODUCTION

Enuresis is a common problem in children. One treatment option is a wetting alarm that provides an alarm when incontinence occurs. A drawback of this approach is that the child is still awakened by wet sheets. Recently, a wearable, wireless ultrasonic bladder sensor became available, the SENS-U, which has the potential to prevent the enuretic event by waking up the child before the bladder is full. In this first feasibility study, the aim is to perform a night-time, home-based evaluation of the SENS-U in children with monosymptomatic nocturnal enuresis (MNE).

PATIENTS AND METHODS

In this study, children (6-12 years) with MNE were included for a one-night monitoring session. During the night, the SENS-U continuously (i.e. every 30 s) estimated the filling status [notifications were deactivated]. In addition, urine volume was collected in a measurement cup (or diaper weight). The total measured natural nocturnal bladder filling (NNBF) cycles was analyzed by descriptive statistics. Before and after the measurement, sleep behavior was assessed by a selection of the Children's Sleep Habits Questionnaire.

RESULTS

Fifteen patients (boys/girls: 13/2) [mean age: 8.6 ± 1.5 years] have been enrolled. One patient was excluded due to inadequate sensor-to-skin contact. For 14 children, 18 NNBF cycles were recorded (voiding diary) of which three patients (21%) had more than one NNBF cycle. The SENS-U was able to successfully detect 83% of the NNBF cycles. The three missed NNBF cycles had a voided volume ≤30 ml, which was at the lower limit of the sensor's detection range. The SENS-U had no effect on sleeping behavior.

CONCLUSION

The SENS-U was able to monitor the natural nocturnal bladder filling successfully in children with monosymptomatic nocturnal enuresis at home, without disturbing their sleep. Future research focuses on investigating the usability of the SENS-U for both diagnostic - and treatment purposes.

Home self-monitoring in patients with asthma using a mobile spirometry system

BACKGROUND

Self-management is an appealing strategy for prevention of asthma exacerbations. This study aimed to evaluate the feasibility and safety of a portable spirometer for unsupervised home spirometry measurements among patients with asthma.

METHODS

A multi-center, prospective, single-arm, open study recruited 86 patients with controlled or partly controlled asthma (41 women, 38.6 ± 10.4 y/o and 45 men, 36.2 ± 12.1 y/o). After a training session, patients performed daily spirometry at home with the AioCare^® mobile spirometry system. Each spirometry examination was recorded and evaluated according to the ATS/ERS acceptability and repeatability criteria. The primary endpoint was defined as three or more acceptable examinations in any given seven-day period (+/- 1 day) during any of the three weeks of the study. The system allowed for online review of measurements by physicians/nurses to provide feedback to patients.

RESULTS

Of 78 patients with complete data, 67 (86%) achieved the primary endpoint. Seventy-five (96%) participants used the device correctly once or more, and 10 (13%) patients succeeded every single day over the three-week follow-up. The rate of acceptable spirometry examinations differed between the sites (p = 0.013). Retraining was required in 20 of 62 (32%) eligible patients, and successful in 8 individuals (40%). Satisfaction with the AioCare^® system was high, 90% of respondents perceived it as useful and user-friendly.

CONCLUSIONS

Self-monitoring of asthma with a connected mobile spirometer is feasible, safe and satisfactory for patients with asthma. It remains to be established whether unsupervised home spirometry measurements may improve early diagnosis and outcomes of self-management in cases of exacerbation or loss of asthma control.

A multicenter randomized clinical trial to evaluate the efficacy of telemonitoring in patients with advanced heart and lung chronic failure. Study protocol for the ATLAN_TIC project

Background

Using technologies of information and communication (TICs) is emerging in medical assistance. TICs application for medical assistance is promising. Its applicability in advanced heart and/or respiratory failure is still controversial because studies have shown methodological weakness which could put in danger their conclusions. Our objective is to evaluate efficacy of the application of home monitoring biological parameters in a multi-level model of coordinated clinical care for patients with chronic diseases with advanced heart (HF) and/or respiratory failure (RF) in comparison with conventional clinical care.

Method

/Design: Multicentric, phase III, randomized, parallel groups, controlled clinical trial. Patients with advanced HF and/or RF were eligible to participate. Patients received medical assistance by a multi-level model of coordinated clinical care with or without home monitoring. Follow up was performed until 180 days after inclusion. Primary efficacy outcome was defined as the percentage of patients with hospitalization/emergency room visits. Secondary efficacy outcomes were hospital admissions, admissions to hospital emergencies and Primary Care Emergencies, number of days of hospital stay, total cost per patient in euros, mortality, change in functional status, quality of life, assistance and technology devices. Intention to treat, as well as per protocol, and incremental cost-effectiveness analysis will be performed. The number of recruits patients per arm is set at 255, a total of 510 patients.

Discussion

This trial could provide some knowledge about the real impact of home monitoring for patients with advanced HF and/or RF within a multi-level model of integrated care.

Risk of subsequent ventricular arrhythmia is higher in primary prevention patients with implantable cardioverter defibrillator than in secondary prevention patients

BACKGROUND

Because of previous ventricular arrhythmia (VA) episodes, patients with implantable cardioverter-defibrillator (ICD) for secondary prevention (SP) are generally considered to have a higher burden of VAs than primary prevention (PP) patients. However, when PP patients experienced VA, the difference in the prognosis of these two patient groups was unknown.

METHODS

The clinical characteristics and follow-up data of 835 ICD patients (364 SP patients and 471 PP patients) with home monitoring feature were retrospectively analysed. The incidence rate and risk of subsequent VA and all-cause mortality were compared between PP patients after the first appropriate ICD therapy and SP patients.

RESULTS

During a mean follow-up of 44.72 ± 20.87 months, 210 (44.59%) PP patients underwent appropriate ICD therapy. In the Kaplan-Meier survival analysis, the PP patients after appropriate ICD therapy were more prone to VA recurrence and all-cause mortality than SP patients (P<0.001 for both endpoints). The rate of appropriate ICD therapy and all-cause mortality in PP patients after the first appropriate ICD therapy was significantly higher than that in SP patients (for device therapy, 59.46 vs 20.64 patients per 100 patient-years; incidence rate ratio [IRR] 2.880, 95% confidence interval [CI]: 2.305-3.599; P<0.001; for all-cause mortality, 14.08 vs 5.40 deaths per 100 patient-years; IRR 2.607, 95% CI: 1.884-3.606; P<0.001). After propensity score matching for baseline characteristics, the risk of VA recurrence in PP patients with appropriate ICD therapy was still higher than that in SP patients (41.80 vs 19.10 patients per 100 patient-years; IRR 2.491, 95% CI: 1.889-3.287; P<0.001), but all-cause mortality rates were similar between the two groups (12.61 vs 9.33 deaths per 100 patient-years; IRR 1.352, 95% CI: 0.927-1.972; P = 0.117).

CONCLUSIONS

Once PP patients undergo appropriate ICD therapy, they will be more prone to VA recurrence and death than SP patients.

Service evaluation of diabetes management during pregnancy in a regional maternity hospital: potential scope for increased self-management and remote patient monitoring through mHealth solutions

BACKGROUND

Pre-gestational and gestational diabetes mellitus are common complications in pregnancy affecting one in six pregnancies. The maternity services are under significant strain managing the increasing number of complex pregnancies. This has an impact on patients' experience of antenatal care. Therefore, there is a clear need to address pregnancy care. One possible solution is to use home-based digital technology to reduce clinic visits and improve clinical monitoring.

METHODS

The aim of this study was to evaluate the antenatal services provided to pregnant women with diabetes who were monitored at the joint metabolic and obstetric clinic at the Southern Health and Social Care Trust in Northern Ireland.

RESULTS

The questionnaires were completed by sixty-three women, most of whom had gestational diabetes mellitus. Most of the participants were between 25 and 35 years of age (69.8%), had one or more children (65.1%) and spent over 2 h attending the clinics (63.9%); 78% of women indicated that their travel time to and from the clinic appointment was over 15 min. Over 70% of women used smartphones for health-related purposes. However, only 8.8% used smartphones to manage their health or diabetes. Less than 25% of the women surveyed expressed concerns about using digital technology from home to monitor various aspects of their health in pregnancy.

CONCLUSIONS

Overall, pregnant women who had or developed diabetes in pregnancy experience frequent hospital visits and long waiting times in the maternity clinics. Most of these pregnant women are willing to self-manage their condition from home and to be monitored remotely by the healthcare staff.

Home telemonitoring of intracranial pressure

BACKGROUND

As technical progress advances, telemonitoring has become an important part of patient care in many areas of medical treatment. However, distanced surveillance of intracranial pressure (ICP) could not be established so far. With the recent introduction of a telemetric ICP measurement probe, new possibilities arise. Here, we report on a new home setup enabling home telemonitoring of intracranial pressure.

METHODS

Twenty patients suffering from disturbances of cerebrospinal fluid circulation, who underwent insertion of a telemetric ICP measurement probe, were provided with medical equipment to read ICP at home and save the data on an internet-enabled computer. Training in handling the equipment was performed during in-patient stay; recorded and uploaded ICP data was then analyzed online. Therefore, the treating medical team was able to access the ICP data via a secure internet connection while telephone conferencing with the patient.

RESULTS

Almost 7400 h of ICP data were recorded at home and evaluated via an internet connection according to the telemonitoring setup. This corresponds to an average record time of about 370 h per patient. ICP profiles were observed following endoscopic treatment, shunting procedures, or valve adjustments. The mean distance between the patients' residence and the consulting hospital was 172 km (range, 16-649 km).

CONCLUSIONS

ICP measurements have become accessible for telemonitoring purposes. This new management of hydrocephalus reflects an alternative method in patient care, especially for those who live far away from specialized centers.

SAFE@HOME - Feasibility study of a telemonitoring platform combining blood pressure and preeclampsia symptoms in pregnancy care

OBJECTIVE

To study the feasibility of a telemonitoring platform for hypertensive disease in pregnancy, consisting of a wireless blood pressure monitor and an app in combination with an integrated preeclampsia symptom checklist.

STUDY DESIGN

Prospective observational study with 14 pregnant women during a 15 weekday study period. For feasibility purposes, compliance was measured by evaluating the number of entered BP and symptom checklists. Comparing all the entered values with the threshold values checked the accuracy of the automatic alerts. Usability and patient satisfaction were measured using questionnaires.

RESULTS

Compliance rates for blood pressure and symptom checklist were 93% and 85% respectively. No false positive or missing alerts were found in the alarm system. The telemonitoring system alarmed 7 times for BP thresholds (3.8% of all received values), Of 167 returned symptom checklists, 93% of symptom alarms could be handled with expectant management because of concurrent normal blood pressure. The majority of participants were satisfied with the system.

CONCLUSIONS

This is the first feasibility study of a telemonitoring platform, combining remote monitoring of BP with preeclampsia symptoms in pregnancy care. Action from health care providers during telemonitoring is only needed in case of alarming combinations of results. This system is potentially very useful in care for women at risk for hypertensive disorders during pregnancy.

Predictive value of gamma-glutamyltransferase for ventricular arrhythmias and cardiovascular mortality in implantable cardioverter-defibrillator patients

Background

Gamma-glutamyltransferase (GGT) is a new predictor of cardiovascular diseases. In this study, we aimed to determine its association with ventricular arrhythmias (VAs) in implantable cardioverter-defibrillator (ICD) patients.

Methods

One hundred and forty patients implanted with ICD or cardiac resynchronization therapy defibrillator with home monitoring were studied retrospectively. The primary endpoint was appropriate ICD treatment of VAs, secondary endpoint was cardiac death.

Results

During a mean follow-up period of 44 ± 17 months, 78 patients (55.7%) experienced VAs, 50 patients (35.7%) were treated with appropriate ICD shocks and 16 patients (11.4%) died due to cardiovascular diseases. GGT was positively correlated with high sensitivity C reactive protein (r = 0.482, P < 0.001), left ventricular end-diastolic dimension (r = 0.175, P = 0.039), New York Heart Association class (r = 0.199, P = 0.018), fasting blood glucose (r = 0.233, P = 0.006) and negatively with left ventricular ejection fraction (r = − 0.181, P = 0.032) and high-density lipoprotein (r = − 0.313, P < 0.001). Based on receiver operating characteristics curve, the cut-off value of GGT = 56 U/L was identified to predict VAs. In Kaplan-Meier survival analysis, GGT ≥56 U/L was associated with increased VAs (P<0.001), ICD shock events (P = 0.006) and cardiovascular mortality (P = 0.003). In multivariate COX regression models, GGT ≥56 U/L was an independent risk factor for VAs (HR 2.253, 95%CI:1.383–3.671, P = 0.001), ICD shocks (HR 2.256, 95%CI:1.219–4.176, P = 0.010) and cardiac death (HR 3.555, 95%CI:1.215–10.404, P = 0.021).

Conclusions

In this ICD population, GGT ≥56 U/L was independently associated with VAs and cardiac death.

Predictive value of rapid-rate non-sustained ventricular tachycardia in the occurrence of appropriate implantable cardioverter-defibrillator therapy

PURPOSE

Rapid-rate non-sustained ventricular tachycardia (RR-NSVT) that meets detection criteria but terminates itself before the delivery of implantable cardioverter-defibrillator (ICD) therapy is not rare in routine ICD interrogation. Whether sustained ventricular tachycardia/fibrillation will occur in a short time after RR-NSVT has not been fully elucidated.

METHODS

Clinical features and follow-up data of 828 ICD patients with home monitoring were retrospectively collected. RR-NSVT characteristics and time interval between the first episode of RR-NSVT and subsequent appropriate ICD therapy were analyzed.

RESULTS

During a mean follow-up of 44.75 ± 20.87 months, 335 episodes of RR-NSVT were documented in 145 patients. A total of 119 patients had both RR-NSVT and appropriate ICD therapy. In multivariate COX regression models, RR-NSVT was an independent predictor of appropriate ICD therapy (HR 7.599, 95%CI 5.926-9.745, P < 0.001), appropriate shock (HR 6.222, 95%CI 4.667-8.294, P < 0.001), and all-cause mortality (HR 2.156, 95%CI 1.499-3.099, P < 0.001). Appropriate ICD therapy was administered after the first RR-NSVT episode in 101 patients, with a median interval of 21 days. Compared to RR-NSVT with appropriate ICD therapy occurring beyond 21 days, RR-NSVT within 21 days prior to appropriate ICD therapy had a longer median duration time (14 s vs. 12 s, P = 0.013), but without significant difference in mean RR interval at initial detection and mean RR interval after episode termination.

CONCLUSIONS

Rapid-rate non-sustained VT was an independent predictor of appropriate ICD therapy and all-cause mortality. The presence of RR-NSVT should be considered a possible herald of more serious cardiac events in ICD patients.

Non-invasive home lung impedance monitoring in early post-acute heart failure discharge: Three case reports

BACKGROUND

Patients discharged after hospitalization for acute heart failure (AHF) are frequently readmitted due to an incomplete decongestion, which is difficult to assess clinically. Recently, it has been shown that the use of a highly sensitive, non-invasive device measuring lung impedance (LI) reduces hospitalizations for heart failure (HF); it has also been shown that this device reduces the cardiovascular and all-cause mortality of stable HF patients when used in long-term out-patient follow-ups. The aim of these case series is to demonstrate the potential additive role of non-invasive home LI monitoring in the early post-discharge period.

CASE SUMMARY

We present a case series of three patients who had performed daily LI measurements at home using the edema guard monitor (EGM) during 30 d after an episode of AHF. All patients had a history of chronic ischemic HF with a reduced ejection fraction and were hospitalized for 6–17 d. LI measurements were successfully made at home by patients with the help of their caregivers. The patients were carefully followed up by HF specialists who reacted to the values of LI measurements, blood pressure, heart rate and clinical symptoms. LI reduction was a more frequent trigger to medication adjustments compared to changes in symptoms or vital signs. Besides, LI dynamics closely tracked the use and dose of diuretics.

CONCLUSION

Our case series suggests non-invasive home LI monitoring with EGM to be a reliable and potentially useful tool for the early detection of congestion or dehydration and thus for the further successful stabilization of a HF patient after a worsening episode.